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Provider: Croydon Health Services NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 11 February 2020

Our rating of the trust stayed the same. We rated it as requires improvement because:

We rated safe, effective, caring, responsive and well-led as requires improvement.

trust, we took into account the current ratings of the services not inspected this time.

Inspection areas

Safe

Requires improvement

Updated 11 February 2020

Our rating of safe stayed the same. We rated it as requires improvement because:

  • In urgent and emergency care we found staff were not always identifying and responding to risks and they did not always comply with infection prevention and control procedures.
  • We found some patient records in urgent and emergency care and medical care (including older people’s care) were not fully complete.
  • In urgent and emergency care, medical care (including older people’s care) and diagnostic imaging staff were not always removing their password protected identity cards from the electronic patients records (EPR). This increased the risk of errors or loss of patient information. 
  • In critical care and medical care (including older people’s care) we found there was a shortage of allied health professionals which meant patients did not always receive care in line with best practice.
  • In all the services we inspected some staff had not completed their mandatory training.
  • Reporting and learning from incidents was not embedded in the services we inspected.

However:

  • In critical care and diagnostic imaging staff were carrying out risk assessments to ensure patients received safe care.
  • We found improvements in the equipment maintenance and areas we inspected appeared clean during the inspection.

Effective

Requires improvement

Updated 11 February 2020

Our rating of effective stayed the same. We rated it as requires improvement because:

  • We found some policies had not been reviewed and updated and some staff were unable to find key documents which should inform their daily practice. 

  • Systems to monitor the effectiveness of care and treatment were not always effective and services were not always meeting the national standards for treatment and care.

  • The uptake of appraisals was low in urgent and emergency care, medical care (including older people’s care) and diagnostic imaging.

  • In diagnostic imaging staff were not able to provide evidence of competency.

However:

  • In critical care we found improvements had been made since it was last inspected. Areas of improvement including staff appraisal and ensuring policies were reviewed and updated.

  • In all the services inspected we found an improvement in staff’s understanding of the role and responsibilities in relation to the Mental Capacity Act (2005).

  • There was good multidisciplinary working in all the services and with external partners.

Caring

Requires improvement

Updated 11 February 2020

Our rating of caring went down. We rated it as requires improvement because:

  • There was a downward trend in response rates and feedback from patients about services.
  • The trust was assessed ‘as much worse’ when compared with similar trusts for the 2018 inpatient survey.
  • In urgent and emergency care there was a lack of privacy for patients in some areas. There was a low response rate to the Family and Friends Test and the number of people who would recommend the service had decreased.
  • In medical care (including older people’s care) there had also been a decrease in the response rate for the Family and Friends Test and the number of people who would recommend the service.

However:

  • During the inspection we observed staff treated patients with kindness and compassion.
  • In critical care we found improvements: staff were more aware of the need to treat patients with privacy and dignity consider their individual needs.
  • Patients we spoke with were positive about the way staff treated them, they described them as ‘kind’ and felt they provided them with explanations and involved them in decisions about their care.

Responsive

Requires improvement

Updated 11 February 2020

Our rating of responsive stayed the same. We rated it as requires improvement because:

  • The trust experienced high bed occupancy, 97-99% which meant that some patients were care for in areas, not always primarily designed for inpatients’. and some patients experienced delays in being discharged from critical care.
  • Length of stay for some patients was longer than the England average
  • Waiting times for patients, including children and young people, in the ED to be admitted, transferred or discharged were not always in line with best practice and the trust was not meeting national standards for waiting times.
  • Complaints and concerns were not always investigated and managed in line with trust policy. They were not always discussed in governance meetings and learning was not always shared with staff.

However:

  • The trust had achieved 92.1% performance against a national RTT standard of 92% (October 2019)
  • The trust was achieving better than the England average for diagnostic waiting times.
  • We saw evidence that the trust was meeting some of the individual needs of patients including bariatric equipment and access to interpreters.
  • Following previous inspections, the trust had employed dedicated mental health nurses to support staff care for patients with mental health needs.

Well-led

Requires improvement

Updated 11 February 2020

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • The trust had arrangements for improving the quality of care and promoting high standards but, these were not effective or embedded across all services. In some of the services we inspected staff had not always identified risks to patients and taken swift action to eliminate or minimise them.
  • Risk registers did not reflect all the risks we found during the inspection.
  • In urgent and emergency care some of the data used to inform the quality and safety of care was inaccurate or unreliable.
  • Some services had a vision for the service going forward but did not have an underpinning plan for how the vision would be delivered, while others did not have a vision.

However:

  • Staff in all the services we inspected told us they were supported and valued by their local leaders and felt they were accessible.
  • In critical care we found improvements in the leadership and action had been taken in response to the concerns found at the previous inspection. Improvements had been made to their systems for monitoring the quality and safety of care and staff had opportunities to meet and review the quality of the service.
  • We found staff were supported to develop and progress their careers.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 11 February 2020

Our rating of use of resources stayed the same. We rated it as requires improvement because:

The trust did not consistently manage its resources to allow it to meet its financial obligations on a sustainable basis and to deliver high quality care

Combined rating

Combined rating summary

Requires improvement

Updated 11 February 2020

Our rating of combined quality and resources stayed the same. We rated it as requires improvement because although some improvements had been made we found insufficient progress in three of the four services we inspected. Systems to monitor the quality and safety of care were not embedded and some improvements found at previous inspections had not been sustained.

Checks on specific services

Community health services for children, young people and families

Requires improvement

Updated 28 September 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not always comply with infection control policies. Staff were not always adhering to the bare below the elbow policy and audits findings were not always actioned.
  • The caseload numbers for health visitors was consistently higher than the recommended numbers. This had not improved since the last inspection.
  • The multidisciplinary working was not fully embedded in the child development centre. This was an ongoing concern since 2016.
  • We did not see evidence that that all services monitored the effectiveness of care and treatment and used the findings to improve them. They did not compare local results with those of other services to learn from them.
  • The service was not consistently meeting the national and local targets for completion of assessments within a set timescale.
  • The service did not have a policy in place to coordinate the transition between children and adult services that covered all the services offered. Where transition plans were in place, this did not comply with National Institute for Health and Care Excellence (NICE) guidance for when this process should start.

  • The service did not consistently plan and provide all services in a way that met the needs of all local people.
  • The service did not always take account of patients’ individual needs. Information on how to access services and other information leaflets were not available in other languages. Staff told us they regularly use relatives to interpret during drop in sessions.
  • Although a risk register was in place, we did not see evidence actions had been taken to mitigate these risks to an acceptable level.
  • The trust collected, analysed, managed and used information to monitor performance against local indicators. However performance for health visitors had been below the expected national and local indicators for the last 12 months.

  • The audit process was not well embedded to assure the leadership team that services were being provided in line local and national guidelines. There was limited audit activity and the actions from audit findings were not consistently followed through.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.

  • Staff kept appropriate records electronic record of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care via mobile devices at the point of care.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.

  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff were aware of guidelines relevant to their service.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were complimentary of the local leadership team.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

Community health services for adults

Requires improvement

Updated 28 September 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Staffing levels were consistently lower than the recommended numbers for the domiciliary speech and language therapy (SALT) team. This had not improved since the last inspection.
  • The trust did not have integrated electronic patient record systems to enable a shared care record. This had not improved since the last inspection.
  • The service did not always take account of patients’ individual needs. Information on how to access services and other information leaflets were not easily accessible in other languages. Staff told us they regularly used relatives to translate during drop in sessions.

  • The service was not meeting referral to treatment times. This was a significant issue for the domiciliary SALT team and there had been no improvement since the last inspection.
  • The service did not always have a satisfactory system to book appointments. In a podiatry clinic, patients were required to ring and book their next appointment and this posed a risk that a person may forget to do this.
  • The trust did not ensure that all staff had the equipment they required to work safely. The trust’s roll out of phone to the community nurses teams had not been completed.
  • The trust did not ensure that patients always had access to interpreters when required.
  • The use of personal phones by staff to contact patients presented a significant data protection risk.
  • Some of the data provided by the trust lacked depth and granularity, in particular staffing and audit information. The service did not provide sufficient data around patient outcomes and therefore missed opportunities to identify potential risks to patients.

However:

  • The service managed patient safety incidents well. Incidents were reported and investigated appropriately. Lessons learned were shared across teams and the wider service.
  • Staff kept appropriate records, paper and electronic, of patients’ care and treatment. Records were clear and up to date.
  • Staff carried out risk assessments for all patients on initial and subsequent visits. Appropriate assessment tools were used to identify and help manage patient risks.
  • Clinical rooms we visited were clean and tidy. We saw evidence of regular and compliant infection control audits across the community adults services.
  • Multidisciplinary working was embedded across community adult services.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service made sure staff were competent for their roles. Staff were well trained, received appropriate supervisions and showed overall good compliance for appraisal rates.
  • Staff encouraged patients to proactively manage their own health. Staff were passionate about supporting patients to improve their own health and wellbeing.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated patients kindly and with dignity.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • All staff we spoke with told us that there was an open and honest culture. Staff were encouraged to report incidents and there was a no blame culture when incidents were reported.